BILL ANALYSIS Ó ----------------------------------------------------------------- |SENATE RULES COMMITTEE | SB 484| |Office of Senate Floor Analyses | | |(916) 651-1520 Fax: (916) | | |327-4478 | | ----------------------------------------------------------------- UNFINISHED BUSINESS Bill No: SB 484 Author: Beall (D), et al. Amended: 9/3/15 Vote: 21 SENATE HUMAN SERVICES COMMITTEE: 5-0, 4/21/15 AYES: McGuire, Berryhill, Hancock, Liu, Nguyen SENATE HEALTH COMMITTEE: 9-0, 4/29/15 AYES: Hernandez, Nguyen, Hall, Mitchell, Monning, Nielsen, Pan, Roth, Wolk SENATE APPROPRIATIONS COMMITTEE: 7-0, 5/28/15 AYES: Lara, Bates, Beall, Hill, Leyva, Mendoza, Nielsen SENATE FLOOR: 40-0, 6/3/15 AYES: Allen, Anderson, Bates, Beall, Berryhill, Block, Cannella, De León, Fuller, Gaines, Galgiani, Glazer, Hall, Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner, Stone, Vidak, Wieckowski, Wolk ASSEMBLY FLOOR: 79-0, 9/8/15 - See last page for vote SUBJECT: Juveniles SOURCE: National Center for Youth Law DIGEST: The bill requires California Department of Social Services (CDSS) to establish a methodology for identifying group homes that have levels of psychotropic dug utilization warranting additional review, and to inspect identified SB 484 Page 2 facilities at least once a year, as specified. Additionally, this bill permits CDSS to share information and observations with the facility and to require the facility to submit a plan within 30 days to address identified risks, as specified. Assembly Amendments add licensing provisions stating that psychotropic medications shall only be used in accordance with the written directions of the prescribing physician and as authorized by the juvenile court. Amendments further add licensing provisions requiring facilities to maintain specified information in the child's records regarding psychotropic medication. Additionally, amendments narrow the scope of the information and measurements required to be considered in establishing the methodology for identifying group homes and strikes specified components to be included in a corrective plan submitted by a facility. Further, amendments strike specific components to be determined by CDSS in monitoring of the facilities implementation of the plan. ANALYSIS: Existing law: 1)Establishes the Community Care Facilities Act, which provides for the licensure and regulation of community care facilities, including group homes, by CDSS, and requires that licensed facilities be subject to unannounced inspections under specified circumstances. (HSC 1500 et seq, and 1534) 2)Requires CDSS to establish a rate classification level (RCL) structure for group homes with a corresponding rate structure according to the level of care and services that will be provided, as specified. (WIC 11462) SB 484 Page 3 3)Permits a group home to be classified as an RCL 13 or 14 if the program only accepts children with special treatment needs and meets other requirements. Additionally, requires the California Department of Health Care Services (DHCS) to annually certify group homes seeking classification as RCL 13 or 14 and permits such facilities to accept minor dependents who are seriously or emotionally disturbed if certain conditions are met. (WIC 11469, WIC 4096.5 and HSC 1502.4) 4)Requires CDSS to publish and make available to interested persons a list or lists covering all licensed community care facilities, other than foster family homes and certified family homes, to include specified information regarding group homes, transitional housing placement providers, community treatment facilities or runaway and homeless youth shelters including complaints, citations, fines and the number of law enforcement contacts made by group homes. (HSC 1536) This bill: 1) Requires CDSS to compile, to the extent feasible and based on information provided by the California Department of Health Care Services (DHCS), specified child welfare psychotropic medication measures developed by CDSS and specified Healthcare Effectiveness Data and Information Set (HEDIS) measures related to psychotropic medication, pertaining to each group home, in order to review and evaluate the use of psychotropic medication in group homes. 2) Requires CDSS to establish a methodology for identifying group homes that have levels of psychotropic dug utilization warranting additional review, in consultation with DHCS. 3) Requires CDSS to inspect a facility identified as appearing to have levels of psychotropic medication utilization warranting additional review at least once a SB 484 Page 4 year, and requires the inspection to include, but not be limited to, a review of the facilities plan of operation, child-to-staff rations, staff qualifications and training, implementation of children's needs and services plan, confidential interviews of residents, and availability of psychosocial and other alternative treatment to the use of psychotropic medication. 4) Permits CDSS to include confidential discussions with former residents, and confidential discussions with physicians prescribing medications to residents. 5) Permits CDSS to do either or both of the following after an inspection: a) Share relevant information and observations with county placing agencies, social workers and probation officers, the court, dependency counsel, or the Medical Board of California. b) Share relevant information and observations with the facility and require the facility to submit a plan, within 30 days, to address any identified risks within the control of the facility. Requires CDSS to approve and monitor implementation of the plan. 6) Provides that psychotropic medications shall only be used in accordance with the written directions of the prescribing physician and as authorized by the juvenile court. 7) Requires facilities to maintain specified information in the child's records regarding psychotropic medication including a copy of any court order authorizing psychotropic medications and a separate log for each medication, as specified. SB 484 Page 5 8) Permits CDSS to implement this bill through all-county letters or similar instructions until regulations are filed and requires emergency regulations to be adopted on or before January 1, 2017 and final regulations to be adopted on or before January 1, 2018. 9) Requires CDSS to monitor the facility's implementation of the plan to determine whether the facility has reduced the rate that psychotropic medications are administered, and the percentage decrease; whether and to what extent alternative less invasive treatments are being provided to residents, and the percentage increase; whether and to what extent 10) Requires CDSS and DHCS in consultation with specified stakeholders to develop additional performance standards and outcome measures that require group homes to implement programs and services to reduce the utilization of psychotropic medications in group homes, including behavioral management programs, emergency intervention plans, and conflict resolution processes. 11) Requires CDSS to post on its internet website a statewide summary of information gathered pursuant to this bill and requires such information be de-identified and aggregate, and does not violate the confidentiality of a child's identity and records. Background Group Homes. Group homes are 24-hour residential facilities licensed by CDSS to provide board and care to foster youth from both the dependency and delinquency jurisdictions. Group home facilities are organized under a system of rate classification levels (RCLs) ranging from 1-14 that are based on levels of professional training and adult-to-child ratios. In practice, the majority of group homes are at or above RCL 10 with nearly SB 484 Page 6 50 percent of group homes at RCL 12. There is wide variation in group home size from as few as six children to more than 100. Group Home Program Statement. Group homes are required to establish a "group home program statement" that includes a training plan that is appropriate for the client population and the training needs and skill level of child care staff. Through regulation, existing law provides that newly hired staff complete at least 24 hours of training within 90 days of being hired, and 40 hours within 12 months, as specified, with all existing staff receiving 20 hours annually. Regulations provide for the minimum topics that must be included (e.g. discipline policies and procedures, behavior problems / psychological disorders, and mental health / behavioral interventions). Social work staff is required to establish a "needs and services plan" for each child that identifies the specific needs of an individual child, and delineates those services necessary in order to meet the child's identified needs. Group homes are required to submit to the department an emergency intervention plan, identifying how the facility will use emergency interventions to address aggressive or assaultive behavior of residents. The plan is required to be designed by the licensee and a qualified behavior management consultant and must be appropriate for the client population served by the group home, and for the staff qualifications and staff emergency intervention training. Psychotropic Medication Use in Children. Concern over the use of psychotropic medications among children has been well-documented in research journals and the mainstream media for more than a decade. The category of psychotropic medication is fairly broad, intending to treat symptoms of conditions ranging from ADHD to childhood schizophrenia. Some of the drugs used to treat these conditions are FDA-approved, including stimulants like Ritalin for ADHD, however only about 31 percent of psychotropic medications have been approved by the U.S. Food and Drug Administration (FDA) for use in children or adolescents. It is estimated that more than 75 percent of the prescriptions written SB 484 Page 7 for psychiatric illness in this population are "off label" in usage, meaning they have not been approved by the FDA for the prescribed use, though the practice is legal and common across all manner of pharmaceuticals. Anti-psychotic medications, used to treat more severe mental health conditions, include powerful brand-name drugs such as Haldol, Risperdal, Abilify, Seroquel and Zyprexa. They have very limited approval by the FDA for pediatric use beyond rare and severe conduct problems that are resistant to other forms of treatment, such as Tourette's syndrome, behavioral symptoms associated with autistic disorder, childhood schizophrenia, and bipolar disorder. However, the off-label use of these anti-psychotics among children is high, particularly among foster children. According to a study published in 2011, children who took antipsychotic medications were likely to suffer ill health effects including "cardiometabolic and endocrine side-effects" as well as significant weight gain. The authors recommended that collaboration between child and adolescent psychiatrists, general practitioners and pediatricians is essential to "reduce the likelihood of premature cardiovascular morbidity and mortality." Compounding the potential for unintended side effects is the use of combinations of psychotropic medications, which foster youth are particularly likely to be prescribed, despite limited evidence of clinical efficacy. Prescribing rates in California. A recent series of stories published in the San Jose Mercury News detailed significant challenges in accessing pharmacy benefits claims data held by the DHCS, and demonstrated that prescribing rates were far higher than had been anticipated by child welfare system experts. Specifically, the data revealed that nearly 1 in 4 youth, and 56 percent of all youth residing in group homes were prescribed at least one psychotropic medication. Furthermore, for those youth prescribed psychotropic medications, nearly 60 percent were prescribed an anti-psychotic - the powerful drug class most associated with debilitating side effects, and 36 SB 484 Page 8 percent were prescribed multiple medications, also referred to as "polypharmacy." Increases observed in California mirror those across the nation - children in foster care represent only three percent of children covered by Medicaid, yet, a study of pharmacy claims in 16 states showed that foster children enrolled in Medicaid were prescribed antipsychotic medications at nearly nine times the rate of other children receiving Medicaid. FISCAL EFFECT: Appropriation: No Fiscal Com.:YesLocal: Yes The Assembly Appropriations Committee states this bill may incur ongoing costs in the range of $300,000 to $600,000 (GF) per year to CDSS to conduct annual site visits at group homes identified as having disproportionately high and inappropriate levels of psychotropic medication use by foster youth. Additionally, the analysis estimates one-time costs of approximately $250,000 (GF) to CDSS to compile information on group homes, consult with stakeholders, and develop a methodology to identify group homes for additional scrutiny and ongoing costs of $130,000 ($65,000 GF) to DHCS to identify, evaluate and collate claims data packages to be used for the purposes of this bill. SUPPORT: (Verified 9/8/15) Advokids Alameda County Foster Youth Alliance All Saints Foster Care Project California Court Appointed Special Advocates California Department of Justice California Youth Connection Children's Advocacy Institute Children's Defense Fund - California Children's Law Center of California Children's Partnership SB 484 Page 9 Consumer Watchdog Dependency Legal Group of San Diego East Bay Children's Law Offices East Bay Community Law Center First Focus Campaign for Children First Place for Youth Humboldt County Transition Age You Collaboration Legal Advocates for Children and Youth Legal Services for Prisoners with Children Mockingbird Society National Association of Social Workers National Center for Youth Law Peers Envisioning and Engaging in Recovery Services Public Counsel's Children's Rights Project Santa Clara Board of Supervisors Youth Law Center 10 individuals OPPOSITION: (Verified9/8/15) None received ASSEMBLY FLOOR: 79-0, 9/08/15 AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins NO VOTE RECORDED: Chávez Prepared by:Sara Rogers / HUMAN S. / (916) 651-1524 9/8/15 19:24:28 SB 484 Page 10 **** END ****